Determining the association between oral malodor and periodontal disease: A case control study

The association between halitosis and periodontitis: a systematic review and meta-analysis

OBJECTIVES

The purpose of this systemic review and meta-analysis was to explore the association between halitosis and periodontitis in observational studies.

MATERIALS AND METHODS

A systematic search covered PubMed, Web of Science, Embase, Scopus, and Cochrane Library until August 18, 2023. Nine observational studies (585 cases, 1591 controls) were analyzed using Stata 17, with odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses considered halitosis assessment methods.

RESULTS

The review found a positive association between halitosis and periodontitis. Significant differences were observed with organoleptic test (OR = 4.05, 95% CI: 1.76, 9.30, p < 0.01) and volatile sulfur compound readings (OR = 4.52, 95% CI: 1.89, 10.83, p < 0.01).

CONCLUSIONS

A positive association was observed between halitosis and periodontitis, supported by significant differences in both organoleptic and volatile sulfur compound readings. However, conclusive findings are limited by statistical heterogeneity, emphasizing the need for additional research.

CLINICAL RELEVANCE

Understanding the halitosis and periodontitis association is clinically significant, informing potential interventions for improved oral health. Further research is vital to refine understanding and guide effective clinical strategies, acknowledging the limitations in current findings.

Enterogenous extra-oral halitosis has a more severe impact on quality of life in females compared to males

Some studies have examined the impact of intra-oral halitosis on quality of life (QOL), but the impact of enterogenous extra-oral halitosis (EOH) on QOL has not been previously studied. We conducted a retrospective analysis of data from 88 patients with enterogenous EOH who visited our online halitosis clinic. A specialized halitosis associated life-quality test (HALT) questionnaire was used to assess QOL of these patients. Spearman correlation analysis was performed to investigate the relationship between HALT score and age. We found that 21 (23.86%) patients were male and 67 (76.14%) patients were female. HALT scores in females were significantly higher than in males (57.6 ± 13.6vs.45.5 ± 11.9,P< 0.001). Additionally, 13 of the 20 items of the HALT questionnaire showed significant differences between the sexes. No correlation was identified between HALT score and age. Therefore, we conclude that: (1) enterogenous EOH has a more severe impact on QOL in females compared to males. (2) More females with EOH visit the offline halitosis clinic compared to males. (3) The QOL of patients with enterogenous EOH does not decline with age.

ORGANOLEPTIC AND HALITOMETRIC ASSESSMENTS DO NOT CORRELATE WELL IN INTRA-ORAL HALITOSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

The gold standard method for diagnosing oral halitosis is the subjective organoleptic measurement. Device-supported methods are also widespread worldwide. The challenges and safety concerns around performing organoleptic measurements during pandemics and the diversity of measuring device alternatives raised our clinical question: which halitometer is the most suitable for diagnosing halitosis?

METHODS

This systematic review was registered in PROSPERO (ID CRD42022320024). The search was performed on March 23, 2022 in the following electronic databases: MEDLINE, Embase, Scopus, Web of Science, and CENTRAL. Adult populations with or without halitosis were included, and patients with systemic diseases were excluded. Organoleptic (subjective) measurement and the device-supported (objective) methods were compared; the primary outcome was the correlation coefficient, and the secondary was the specificity and sensitivity of the devices. QUADAS-2 and QUADAS-C were used to evaluate the risk of bias in the studies. Random-effects meta analyses were performed on the outcomes, and the secondary outcomes were plotted on a common ROC plot.

RESULTS

A total of 1231 records were found in the 5 databases. After the selection process, 76 articles were eligible for the systematic review, and 14,635 patients were involved in the qualitative analysis. The pooled Spearman's correlation coefficient (c.c.) for sulfide monitors was 0.65; 95% CIs: [0.53-0.74]; I2 = 95%, P < .01. The pooled Spearman's c.c. for portable gas chromatographs was 0.69; 95% CIs: [0.63-0.74]; I2 = 12%, P < .01. The pooled Spearman's c.c. for gas chromatographs was 0.76; 95% CIs: [0.67-0.83]; I2 = 0%, P < .01.

DISCUSSION

None of the most commonly used halitometers proved to be significantly superior to the others. Halimeter and OralChroma measurements did not correlate well with the organoleptic level of oral halitosis in adults. Therefore, better halitometers need to be developed as an alternative to organoleptic measurements.

Non-Surgical Periodontal Treatment Impact on Subgingival Microbiome and Intra-Oral Halitosis

The purpose of this study was to characterize and compare subgingival microbiome before and after periodontal treatment to learn if any changes of the subgingival microbiome were reflected in intra-oral halitosis. We tested the hypothesis that intra-oral halitosis (Volatile sulfur compounds levels) correlates with corresponding subgingival bacterial levels before and after periodontal treatment. Twenty patients with generalized periodontitis completed the study. Subgingival plaque samples were collected at baseline and 6-8 weeks after nonsurgical periodontal therapy. Full-mouth periodontal status assessed probing depth (PD), clinical attachment loss (CAL), gingival recession (REC), bleeding on probing (BoP), PISA and PESA. Halitosis assessment was made using a volatile sulfur compounds (VSC) detector device. Periodontal measures were regressed across VSC values using adjusted multivariate linear analysis. The subgingival microbiome was characterized by sequencing on an Illumina platform. From a sample of 20 patients referred to periodontal treatment, 70% were females (n = 14), with a mean age of 56.6 (±10.3) years; full-mouth records of PD, CAL, BOP (%) allowed to classify the stage and grade of periodontitis, with 45% (n = 9) of the sample having Periodontitis Stage IV grade C and 95% (n = 19) had generalized periodontitis. The correlation of bacterial variation with VSCs measured in the periodontal diagnosis and in the reassessment after treatment were evaluated. Fusobacterium nucleatum, Capnocytophaga gingivalis and Campylobacter showaei showed correlation with the reduction of VSC after periodontal treatment (p-value = 0.044; 0.047 and 0.004, respectively). Capnocytophaga sputigena had a significant reverse correlation between VSCs variation from diagnosis (baseline) and after treatment. Microbial diversity was high in the subgingival plaque on periodontitis and intra-oral halitosis participants of the study. Furthermore, there were correlations between subgingival plaque composition and VSC counting after periodontal treatment. The subgingival microbiome can offer important clues in the investigation of the pathogenesis and treatment of halitosis.

ISP good clinical practice recommendations for gum care

Oral health is vital for the general well-being, overall body health and the quality of life throughout our lifetime. Most of the oral diseases and conditions are largely related to the maintenance of oral hygiene, lacking that people suffer from diverse oral diseases at different times in their life. With greater life expectancy, the individuals have teeth involved with periodontal diseases that would not only require professional care but also home gum care for them to last a lifetime. Indian Society of Periodontology (ISP) has recognized the need for systematic documents to update everyday clinical practice of general dental practitioners and have provided evidence-based consensus documents, namely good clinical practice recommendations from time to time to raise the oral health-related awareness and standards of oral healthcare delivery across the country. The current set of clinical practice recommendations focused to "Gum Care for All", is aimed at emphasizing and enhancing the awareness regarding oral health promotion, maintenance, and disease prevention. Twenty-five subject matter experts from across the nation, prepared these recommendations after a thorough literature review and group discussions. The document has been prepared in three distinct sections, namely pretherapeutic, therapeutic, and post therapeutic, to provide guidance during the respective phases of patient management and may serve as a quick and concise reference to the readers. The guidelines shall provide the distinct definitions, signs and symptoms, treatment required; recall visit specifications for plausible clinical case situations, home care advice regarding maintenance of oral hygiene including information on brushing technique, care and change of brush, use of interdental aids, and mouthwashes, etc. The document should advocate and guide the combined efforts of general dentists, and the population at large toward an empowered, evidence based, integrated, and comprehensive oral health care, which shall enhance the healthful functioning and longevity of the dentition and general health of the individual.

Revisiting Standard and Novel Therapeutic Approaches in Halitosis: A Review

Halitosis, or bad breath, is an oral health problem characterized by an unpleasant malodor emanating from the oral cavity. This condition can have different origins and causes a negative burden in social interactions, communication and quality of life, and can in uncommon cases be indicative of underlying non-oral non-communicable diseases. Most cases of halitosis are due to inadequate oral hygiene, periodontitis and tongue coating, yet the remaining proportion of cases are due to ear-nose-throat-associated (10%) or gastrointestinal/endocrine (5%) disorders. For this reason, the diagnosis, treatment and clinical management of halitosis often require a multidisciplinary team approach. This comprehensive review revisits the etiology of halitosis as well as standard and novel treatment that may contribute to higher clinical success.

Efficacy of a Zinc Lactate Mouthwash and Tongue Scraping in the Reduction of Intra-Oral Halitosis: A Single-blind, Controlled, Crossover Clinical Trial-A Pilot Study

Intra-oral halitosis is defined as an unpleasant odor that comes out of the mouth. The aim of this study was to investigate the effect of zinc lactate mouthwash and tongue scraping on intra-oral halitosis. The study was conducted on 60 volunteers that were divided into two groups and fol-lowed two types of 14-day oral hygiene protocols on a cross-over basis after a 7-day wash-out period. One protocol was based on tooth brushing only, while the other was based on additional mouth rinsing with a zinc lactate product and tongue scraping. Morning mouth breath was as-sessed organoleptic and by volatile sulfur compound concentrations. The highest mean organo-leptic and volatile sulfur compound measurement values were found in the tooth brushing without mouth washing and tongue scraping oral hygiene protocol (p < 0.05). The zinc lactate mouthwash combined with tongue scraping appears to be an important hygienic procedure to reduce breath odor.

Investigation of oral malodor prevention by dentifrices as measured by VSC reduction

The oral malodor reduction efficacy of dentifrices containing stannous fluoride (SnF₂) or zinc plus arginine (Zn/Arg) was evaluated using a halimeter to measure volatile sulfur compounds (VSCs) in two randomized, controlled, single-blind, cross-over pilot clinical trials. Study 1 (N= 16) had five 1100 ppm F dentifrices and five treatment periods: negative control (NC): 0.243% sodium fluoride (NaF); SnF₂A: 0.454% SnF₂+ pyrophosphate; SnF₂B: 0.454% SnF₂+ sodium hexametaphosphate; SnF₂C: 0.454% SnF₂+ citrate; and SnF₂D: experimental 0.454% SnF₂with increased bioavailable Sn. Study 2 (N= 16) had four 1450 ppm F dentifrices and four treatment periods: NC: 0.1% NaF + 0.76% sodium monofluorophosphate; Zn/Arg: NaF + zinc + arginine; SnF₂E: 0.454% SnF₂+ 0.078% NaF + sodium hexametaphosphate; SnF₂F: 0.454% SnF₂+ 0.078% NaF + citrate. Each period took 96 h; baseline (day 0) morning to day 4 morning. Subjects brushed 2x/day with the treatment dentifrice. VSC levels were measured in the morning, prior to morning brushing, on days 0 and 4. Changes in VSC scores from day 0 to day 4 were assessed using a mixed-model analysis of covariance for cross-over studies. In study 1, SnF₂dentifrices B, C and D showed statistically significant reductions (31.3%, 24.8%, 34%, respectively) in VSC scores versus baseline (p< 0.001); the benefits of these treatments versus NC and SnF₂dentifrice A were statistically significant (p⩽ 0.001). In study 2, SnF₂dentifrices E and F showed statistically significant reductions (31.2%, 22.1%, respectively) in VSC scores versus baseline (p⩽ 0.010); the benefits of these treatments versus NC and the Zn/Arg dentifrice were statistically significant (p⩽ 0.035). The Zn/Arg dentifrice showed a significant increase of 35.2% (p< 0.001) in VSC scores versus baseline. These studies demonstrated that SnF₂dentifrices can provide significant oral malodor reductions, but the benefit is formulation dependent. The presence of SnF₂is not sufficient to ensure efficacy. The Zn/Arg dentifrice increased VSC levels, indicating greater malodor.Clinical Trial Numbers: 20190429 and 20191028.

The Relationship between Volatile Sulfur Compounds and the Severity of Chronic Periodontitis: A Cross-sectional Study

Background:

Halitosis is a problem that is often ignored or undervalued. It is not considered a major clinical issue; thus, little is carried out to eradicate it. Little is known about the relationship of malodorous breath with the severity of periodontitis. Hence, the study aimed to investigate the relationship between volatile sulfur compounds (VSCs) and chronic periodontitis.

Materials and Methods:

According to the severity of chronic periodontitis, 80 patients were categorized into four groups (mild, moderate, severe, and control). Probing depth and clinical attachment level were measured. Portable sulfide monitor (Halimeter) is used to assess VSCs. Statistical analyses were conducted using R studio (Northern Ave, Boston).

Results:

The differences in the VSC levels among the four groups were found to be statistically significant. The greater the severity of periodontitis, the higher the VSC levels found (P < 0.001). Male had higher levels of VSCs than female (225 and 180.53 parts per billion [ppb], respectively). The lowest mean level of VSCs was found in the subjects aged 15–29 years (161.79 ppb); the mean values increased with the age, reaching 282.89 ppb in subjects aged >59 years.

Conclusion:

Highly significant differences were found in the VSC levels among different severities of chronic periodontitis. Moreover, an age-related increase in the VSC levels was determined. In addition, male had higher concentration of VSCs than female.

The association between periodontal diseases and halitosis among Saudi patients

Objectives

To assess the relationship between the presence of periodontal disease and halitosis.

Methods

A total of 120 patients were enrolled and divided into 2 groups, 60 patients with probing depth (PD) > 3.0 mm (group 1) and 60 patients with PD ≤ 3.0 mm (group 2). Clinical parameters including, plaque index (PI), bleeding index (BI), and PD were obtained. Breath samples were collected and analyzed using a portable gas chromatograph to measure the concentration of volatile sulfur compounds (VSC).

Results

Halitosis was found to affect 58.3% of the total patients. The means of PI, BI, and VSC were significantly higher in group 1 (PD > 3.0 mm) than in group 2 (PD ≤ 3 mm).

Conclusions

The percentage of patients suffering from halitosis in the Saudi population are comparatively high. In addition, there was a positive association between periodontal disease and halitosis.

The Impact of Oral Health on Work Performance of Japanese Workers

OBJECTIVE

The aim of this study was to investigate the association between oral health and work performance measured as absenteeism and presenteeism.

METHODS

Study participants were employees (mean age: 42.7 ± 11.4 years) of 11 companies in Japan. Oral examination and self-administered questionnaires provided information on industrial category, work schedule, work performance (absenteeism and presenteeism), and smoking status.

RESULTS

The proportion of absenteeism (2.7%) or presenteeism (6.8%) of workers caused by oral health problems was low. Logistic regression analysis showed that the risk of absenteeism due to oral health problems was not significantly related to occupation or oral health status. However, the risk of presenteeism caused by oral health problems was 2.01 (95% confidence interval, 1.03 to 3.92) times higher among participants with periodontitis.

CONCLUSIONS

Periodontal disease is associated with presenteeism of workers. It is considered that the periodontal disease countermeasure in the workplace should be provided.

Halitosis: prevalence, risk factors, sources, measurement and treatment - a review of the literature

Halitosis, an offensive breath odour, has multiple sources and negative impacts on people's social interactions and quality of life. It is important for health care professionals, including general physicians and dental professionals, to understand its aetiology and risk factors in order to diagnose and treat patients appropriately. In this study, we have reviewed the current literature on halitosis regarding its prevalence, classification, risk factors, sources, measurement and treatment.

A new technique for tongue brushing and halitosis reduction: the X technique

The tongue is one of the primary sources of halitosis. The manual or mechanical removal of biofilm is known to decrease oral malodor.

Prevalence and relevant factors of halitosis in Chinese subjects: a clinical research

BACKGROUND

The aim of this study was to investigate the prevalence of halitosis among Chinese subjects and to analyze the associated factors that influence halitosis.

METHODS

This study included subjects complaining of halitosis who came to the clinic between 2014 and 2016. Questionnaires were used to obtain general information from patients. An organoleptic test was conducted, and volatile sulfur compounds measurement was obtained to assess halitosis. In conjunction with these tests, the oral health status of each patient was recorded.

RESULTS

In total, there were 205 samples entered into data analysis, and the patients' age ranged from 18 to 71 years (mean ± SD: 32.44 ± 10.31). Of these patients, 65.9% had an organoleptic score ≥ 2, and 41% of patients had a volatile sulfur compound level ≥ 110 ppb. The findings indicated that the prevalence of halitosis was higher in males than in females (55.6% vs. 44.4%, respectively, P = 0.018). Several factors including the duration of bad breath, rhinitis, tongue coating and periodontal conditions were found to be associated with the organoleptic score. Tongue coating was also associated with the volatile sulfur compound level.

CONCLUSIONS

Among these subjects, 65.9% had halitosis. Oral health status was strongly associated with halitosis, and tongue coating was the most important factor.

A randomized cross-over short-term study on the short-term effects of a zinc-lactate containing mouthwash against oral malodour

AIM

This randomized controlled cross-over-design-study investigated short-term effects on oral malodour of a zinc-lactate-containing mouthwash.

MATERIALS AND METHODS

Sixteen subjects (18-65 years) with an organoleptic score (OLS) ≥2 were included. Following rinses were used: (A) a zinc-lactate-containing mouthwash (10 ml/30 s); (B) a zinc-lactate-containing mouthwash (15 ml/60 s); (C) a rinse without zinc-lactate (3 droplets/10 ml tap water/30 s) and (D) tap water (10 ml/30 s). Each formulation was evaluated by two blinded examiners comparing OLS and three volatile-sulphur-compounds (VSC; H₂S (hydrogen sulphide), CH₃SH (methyl mercaptan) and (CH₃)₂S (dimethyl sulphide)) before, 1 and 3 h after rinsing. Subject's perception was investigated with a visual-analogue-scale. Linear mixed models were used to compare all parameters simultaneously with respect to the four treatment groups with a significance level α < 0.05.

RESULTS

OLS was significantly reduced by A and B compared to C and D after 3 h (p < 0.006). The sum of the 3 VSCs as well as H₂S alone were significantly reduced by rinses A and B after 1 and 3 h compared to rinses C and D (p < 0.05). Significant differences were found between the four rinses for 'Taste' (p = 0.003), for 'Change of mouth feeling' (p = 0.001), for 'Feeling of freshness' (p = 0.002) and for 'Effectiveness' (p = 0.002) in favour of A & B.

CONCLUSION

A zinc-lactate-containing mouthwash reduced OLS and VSC over a period of 3 h with favourable patient reported outcomes.

Reliability, Accuracy, and Use Frequency of Evaluation Methods for Amount of Tongue Coating

OBJECTIVE

To classify the evaluation methods for amount of tongue coating (TC) and investigate their reliability, accuracy, and frequency of use.

METHODS

Articles published from 1985 to 2015 were searched for evaluation methods for the amount of TC in PubMed and the Cochrane Library. Only clinical researches were included except protocol articles. The methods were classified according to their characteristics.

RESULTS

Finally, 113 articles were selected. The evaluation method for the amount of TC from the articles was classified into 4 types: intuitive, specificative, computerized, and weighing TC. The reliability in the intuitive and specificative methods (κ =0.33-0.92) showed varying levels among the studies. In general, the amount of TC calculated by the specificative method (Spearman's r=0.68-0.80) was more strongly related to the directly measured value than to the value estimated by the computerized method (Pearson's r=0.442). The number of articles published on this topic has increased consistently, and the specificative method was the most frequently used. Despite the higher reliability of the computerized method, it has not been widely used.

CONCLUSIONS

The high prevalence of the specificative method would continue in clinical practice because of its convenience and accuracy. However, to establish higher reliability, the limitation of the subjectivity of the assessors should be overcome through calibration training. In the computerized method, novel algorithms are needed to obtain a higher accuracy so that it can help the practitioners confidently estimate the amount of TC.

Comparison of oral malodors before and after nonsurgical periodontal therapy in chronic periodontitis patients

Background/purpose

Periodontal diseases have been considered as a source of oral malodor or halitosis. Improvement of oral malodor in chronic periodontitis patients has recently been observed after nonsurgical periodontal therapy in combination with tongue cleaning and/or chlorhexidine mouth rinsing. The present study, however, evaluated the impact of nonsurgical periodontal therapy alone on the oral malodor in chronic periodontitis patients by comparing the intraoral concentrations of volatile sulfur compounds (VSCs) before and after nonsurgical therapy.

Materials and methods

Using a sulfide monitor, the total VSCs in exhaled breath were measured in 80 patients with chronic periodontitis prior to and 1 month after nonsurgical periodontal therapy (re-evaluation phase). Malodor was defined as a VSC score > 75 parts per billion (ppb) and > 110 ppb, respectively.

Results

Significantly lower level of VSCs was recorded at periodontal re-evaluation (55 ± 9.7 ppb) than before treatment (89 ± 16.3 ppb). Before treatment, 27 (34%) patients were considered to have malodor, defined as VSCs > 75 ppb. After treatment, 16 patients (20%) had VSC scores > 75 ppb, including 10 of 27 patients with baseline VSC scores > 75 ppb and six of 53 patients with baseline scores ≤ 75 ppb. The risk of malodor differed significantly before and after treatment (P = 0.035, McNemar's test). However, when malodor was defined as VSCs > 110 ppb, the difference in risk showed only borderline significance (P = 0.077).

Conclusion

On the basis of our findings, we suggest that nonsurgical periodontal therapy has a mild impact on oral malodor.